The Center for Medicare Services (CMS) Two Midnight Rule: Policy at Odds with Reality

Introduction: To reduce costs, CMS implemented new policies governing which patients are automatically admitted as inpatients (staying greater than “two midnights”) and which require additional justification with physician documentation to be admitted. This study examines procedures missing from the Medicare Inpatient Only (MIO) list and uses national data to evaluate its appropriateness.

Method: Non-MIO procedures were identified from the current MIO list. Utilizing relevant billing codes, procedures were queried in the National Surgery Quality Improvement Program(NSQIP) database for length of stay(LOS), percentage requiring >2 day stay, and inpatient status from 2005-2012. A separate analysis was performed for patients qualifying for Medicare, namely those 65 years old or older.

Results: A majority of patients stayed more than two days for several procedures not included on the MIO list (Table 1), including component separation with 79.1% of patients staying >2days with a mean LOS of 9.0±13.6days, diagnostic laparoscopy 64.2%>2days LOS, mean 6.3± 9.0days, laparoscopic splenectomy 60.0%>2days LOS, mean 5.9±12.3days, open recurrent ventral hernia repair 58.2% >2 days LOS, mean 5.3±13.3days, laparoscopic esophageal surgery 46.4%>2days LOS, mean 5.5±11.9 days, and open ventral hernia repair 34.8%>2day LOS, mean 3.3±8.2 days. In patients ≥65 years, the average LOS was longer than the general population. In many procedures 60-88% of patients required >2 nights in the hospital with an average LOS of 5.2 days to 10.7 days (see table). In this older group, 40.2% of laparoscopic appendectomy patients and 38.7% of laparoscopic cholecystectomy required more than 2 nights in the hospital.

Conclusions: Commonly encountered non-MIO surgical procedures have national precedents for inpatient status. Before enacting policy, CMS and other regulatory bodies should consider current data to ensure rules are evidence-based and applicable. Inaccurate and onerous regulations impede patient care and obstruct provider productivity.

Table 1-Length of Stay for Common non-MIO List Procedures

%patients with LOS>2 days

%patients age ≥65 years with LOS>2 days

Average LOS(days)— Patients ≥ age 65

Component Separation

79.1%

85.8%

10.45±14.5

Diag Lap

64.2%

81.8%

8.8±9.9

Open Recurrent Ventral Hernia

58.2%

64.8%

6.2±9.4

Lap procedure of the esophagus

46.4%

61.8%

7.4±11.6

Open ventral hernia repair

34.5%

51.7%

5.2±8.8

Abdominoplasty

26.7%

55.7%

5.4±8.8

Lap incisional hernia repair

24.7%

31.0%

2.7±7.8

Lap recurrent ventral hernia repair

24.7%

32.4%

2.5±3.8

Lap cholecystectomy

24.0%

38.7%

3.3±6.5

Lap primary ventral hernia repair

17.9%

29.9%

2.6±6.9

Lap appendectomy

17.2%

40.2%

3.5±8.8

Simple mastectomy

16.0%

10.3%

1.6±6.4

Parotidectomy/Submandibular gland excision

11.2%

17.0%

1.9±3.7

Partial thyroidectomy

8.2%

5.8%

1.5±7.9

Total thyroidectomy

6.2%

8.4%

1.6±3.2

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